1. Biases and debiasing Pat Croskerry MD, PhD

2. Affective Cognitive Social/Cultural
The Biases
Affective
Cognitive
Social/Cultural

3. Affective Bias
When the affective state of the decision maker adversely affects decision making
Due to a failure in rational/logical decision making
Usually due to ‘hot emotion’ (vivid-tepid continuum)
There are about 20 known affective biases
Universal
Predictable
Correctable (affective de-biasing)

4. The Emotional Spectrum
HOT
COOL

5. Cognitive and affective debiasing

6. Four major issues Getting people to recognize there is a problem
Accepting that change must occur
Choosing an appropriate debiasing strategy
Teaching and sustaining debiasing strategies

7. Many clinicians are unaware of the problem…

9. And some people will never change…

11. So how do we become better decision makers ?

12. Most of our biases live in the intuitive mode (System 1)
REMEMBER
Most of our biases live in the intuitive mode (System 1)

13. The most important step is de-coupling from System 1

14. T Calibration Diagnosis Type 1 Processes Pattern Recognition Patient
RECOGNIZED
Pattern Recognition
Patient
Presentation
Pattern
Processor
Executive
override
Dysrationalia
override T
Calibration
Diagnosis
Repetition
Type 2
Processes
NOT
RECOGNIZED

15. Executive override Thinking about how we think Reflection Mindfulness
Metacognition
System 2 monitoring of System 1
System 2 modulation of System 1
Cognitive decoupling from System 1
Cognitive debiasing

16. We need to maintain
a feral vigilance
to detect biases

17. It ain’t easy Even though bias detected
Very unlikely one strategy works for all
Need for multiple approaches
Very unlikely one shot will work
Need for multiple innoculations
Need for extra vigilance in critical conditions
Need for lifelong maintenance

18. Issues that impede cognitive and affective de-biasing

19. Variable Descriptor Clinical relevance Lack of awareness
Cognition has not been seen as the business of medicine. Cognitive processes are not usually studied by clinicians except in disease states such as brain injury, dementia, autism and others.
Lack of awareness
Many clinicians are naïve about cognitive processes and unaware that cognitive and affective biases may significantly impair clinical judgment. Usually, not covered in medical undergraduate or postgraduate training.
Invulnerability to cognitive and affective error
Some clinicians may be aware of cognitive and affective biases but do not believe that they are vulnerable to them (cognitive egocentrism, optimism bias, blind spot bias) or that they might affect their own practice.
Myside bias
If clinicians (and researchers) believe cognitive and affective bias are unimportant in clinical reasoning, they will have a prevailing tendency to evaluate data, evidence, and hypotheses in a manner supportive of their opinions.
Status quo bias
Cognitive de-biasing requires Type 2 processing and significant cognitive effort. It is considerably easier to continue with the status quo, rather than make the effort to learn a new approach and change current practice.
Belief perseverance
The human tendency is to bolstering existent beliefs rather than searching for new approaches. Established beliefs are remarkably resilient. Despite evidence that contradicts or discredits a belief, we may continue to hold it.
Overconfidence
Clinicians’ overconfidence in their own judgments may be the most powerful factors that contribute to diagnostic failure. Hubris and lack of intellectual humility characterize the uncritical thinker.
Vivid-pallid dimension
Discussions of cognitive processes per se are dry, abstract and uninteresting to the medical mind. They typically lack the vividness and concrete nature of clinical disease presentations that are more appealing to clinicians.

20. What strategies do we have for debiasing?

21. Cognitive Debiasing Strategies
Teach the basic rationale: DPT and where errors are
Review the main cognitive and affective biases
Teach specific strategies for particular biases
Forcing functions
Encourage decision maker to get more information
Encourage metacognition and reflection
Slow down
Think the opposite
Maintain a healthy skepticism
Group decision making
Educating intuition
Less hubris, less overconfidence

22. High Risk Situations Cognitive overloading Fatigue
Sleep deprivation/sleep debt
Negative mood/affective state
Alcohol/drug influence

23. High risk situations
Is this patient handed off to me from a previous shift     Diagnosis momentum, framing                
Was the diagnosis suggested to me by the patient, Premature closure, framing
       nurse or another MD ? 
Did I just accept the first diagnosis that came Anchoring, availability, search satisficing, to mind ? premature closure    
Did I consider other organ systems besides the                Anchoring, search satisficing, premature closure
obvious one?
Is this a patient I don’t like for some reason ?                  Affective bias
Was I interrupted/distracted excessively while All biases
evaluating this patient?            
Did I sleep poorly last night? All biases
Am I feeling fatigued right now?    All biases                      
Am I cognitively overloaded or                                All biases over-extended right now?
Am I stereotyping this patient?                                         Representative bias, affective bias, anchoring, fundamental attribution error
Have I effectively ruled out must-not-miss diagnoses?   Anchoring, overconfidence, confirmation bias
                                   

25. The Ultimate Debiasing Strategy?
What else could this be?